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Medical History, 2000, 44: 21-56

The "Matchbox on a Muffin":The Design of Hospitals in the Early NHS

JONATHAN HUGHES*

Although I am not myself a devotee of bigness for bigness sake, I would rather be kept alivein the efficient if cold altruism of a large hospital than expire in a gush of warm sympathy ina small one.'

The role of architecture within Britain's National Health Service has received littleattention beyond the discussion of technical matters. Yet architectural design is nota neutral, value-free resource from which architects draw as desired. The layout,design and styling of buildings can manifest the geographically- and temporally-localized thinking, aspirations and prejudices of their designers and clients. This wasespecially so during the early years of the NHS when, in the late-1950s and early-1960s, significant capital expenditure was once again channelled towards majorhealthcare schemes. And, since this state funding was largely directed towards generalhospital schemes, architects were forced to re-engage with hospital design after a gapof almost two decades, to update inter-war thinking with contemporary continentalEuropean and North American ideas.

This article seeks to trace the conflation of clinical, social and architectural ideaswhich justified, in the early post-war period, the development of a particularlyinfluential architectural solution for the modern hospital: the ward tower set on awider, lower block of accommodation. Whilst not the only possible solution to thearchitectural needs of the modern hospital, this model-known as the "matchboxon a muffin"2-was certainly the most influential during the early years of the NHS,and underwrote schemes both on tight inner-city sites and more expansive greenfieldlocations. This article reconsiders the development of this model, and marshals twocase studies to provide accounts of the ways in which architects came to terms withthe changing demands of the modern hospital in the late 1950s. What emerges isthe desire to provide hospital architecture with a symbolic form expressive of themodernity of the healthcare to be found within. Moreover, the reactions to thesebuildings highlight the extent to which such designs could equally be aligned bycritics with a crude Taylorist functionalism. Far from being a neutral statement of

* Dr Jonathan Hughes, 15 Hamilton House, 18 are reproduced by courtesy of King's CollegeSouthampton Row, London WC1B 4HA. London.

'Aneurin Bevan, MP, Minister of Health, inI should like to acknowledge the assistance of the Commons debate on the NHS Bill, 30 Aprillate Stuart Gray, William Howitt and staff at 1946.Guy's and St Thomas' Hospitals in the 2 It is possible that the originator of the termproduction of this article. Figures 2, 16, 17, and was Richard (later Lord) Llewelyn-Davies.

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Jonathan Hughes

clinical and architectural modernity, the "matchbox on a muffin" offered a solutionwhich can be understood only in relation to a series ofkey aesthetic and programmaticassumptions.

Hospital Building in the New NHS

The most remarkable feature of the new NHS hospital service's capital allocationduring the 1950s was its insignificance. Compared to the £430m and £57m capitalexpenditure allocated in 1954 to housing and schools respectively, the 10m forhospital investment was insignificant,3 only one-third of its pre-war level.4 That thehospital building stock was in need of improvement was not in doubt: of the 2,800hospitals (and 500,000 beds) inherited by the NHS in 1948, 45 per cent had beenbuilt before 1891, and 21 per cent before 1861-many being former Poor Lawworkhouse infirmaries. Across the country the Ministry of Health found "a similarpattern of deficiencies, outmoded physical facilities, maldistribution and unevenquality of services, shortage of nursing and medical staff, inadequate training,idiosyncrasy and lack of co-ordination, and inadequate funding, owing to eitherpoverty or neglect."5Of course the hospital authorities' attention had been diverted by the administrative

upheavals of nationalization, and the task of recommissioning 35,000 unstaffed beds(approximately 70 medium-sized hospitals) to cope with the demand unleashed bynationalization.6 Yet by the mid-1950s the lack of new hospital schemes presentedcause for public concern; as the Daily Telegraph noted in 1955, "The 14 new townsnow rising in Britain have houses, churches, factories, schools, shops, cinemas, inns,but not a hospital between them."7 The problem seemed to lie in the enormous costof the NHS itself, a cost which early on regularly (and spectacularly) outstrippedofficial estimates. Prompted by attacks on the outlay on the NHS, the governmentintroduced charges for dentures and spectacles (and subsequently prescriptions) inMay 1951. Clearly, restraining capital expenditure offered a far easier and apparentlypolitically neutral source of savings.By 1953, the fear of NHS spending spiralling out of control brought the ap-

pointment by the Minister of Health, lain Macleod, of a Committee of Enquiry intothe Cost of the NHS (the Guillebaud Committee). By re-estimating and deflatingNHS expenditure to obtain the real cost of the service, the Committee's 1956 reportnot only gave the NHS a clean bill of health,8 but also recommended a seven-yearprogramme of capital investment of £30m per annum.9 The recommendations went

3J 0 F Davies, 'The general design problems 6Peter Stone, 'Hospitals: the heroic years',of the hospital from the medical point of view', Architects' Journal, 15 December 1976, pp.RIBA Journal, October 1954, pp. 499-503. 1121-48.

'Ministry of Health, Report of the Committee 7J Pringle, 'Crisis in hospitals', Dailyof Enquiry into the Cost of the National Health Telegraph, 9 February 1955; quoted in Webster,Service, London, HMSO, 1956, Cmd. 9663, para. op. cit., note 5 above, p. 341.64. 8Ministry of Health, op. cit, note 4 above,

5Charles Webster, The health services since the para. 23.war, vol. 1, Problems of health care, the NHS 9 Ibid., paras. 59-65, 213.before 1957, London, HMSO, 1988, p. 261.

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The Design of Hospitals in the Early NHS

unheeded, and throughout the 1950s official proclamations of increased capitalexpenditure disguised a little-changed situation. The meagre funding of additionalpsychiatric facilities in 1954/5 (the "mental million") was followed by the February1955 (unrealized) declaration of a stepping-up of the hospital building programme,to £20m in 1958/9, and £31m in 1961/2'0-albeit initially only £2m more than the1954/5 austerity funding. However, the Ministry did earmark money for majorbuilding schemes costing over £250,000, thereby benefiting the teaching hospitals,which side-stepped Ministry parsimony by drawing upon jealously-guarded en-dowment funds." Meanwhile, ministers pointed to the commencement of generalhospital projects at Hensingham (near Whitehaven), Swindon, Crawley, Harlow,Truro, Huddersfield, Swansea, Coventry and Wythenshawe,'2 and later at NorthwickPark, Hull and Barking.'3 Yet by 1959, the Minister of Health, Derek Walker-Smith,could announce the completion of only six projects in England and Wales,'4 of whichonly the first phase of the Princess Margaret Hospital, Swindon, was part of ageneral hospital scheme. Scotland's health services (under a different cabinet minister)fared slightly better, with developments at Edinburgh's Western General Hospital,Kirkcaldy's Victoria Hospital and the new Bellshill Maternity Hospital. So didNorthern Ireland, whose Altnagelvin Hospital by architects Yorke Rosenberg &Mardall was, in 1960, possibly the first major post-war hospital development to becompleted in the United Kingdom. And so, in 1959, a BMA-sponsored report intohospital building could still condemn the nineteenth-century conditions in whichtwentieth-century medicine was largely being delivered and demand a ten-year,£750m rebuilding programme.'5 Indeed, it was not until 1961, with Enoch Powell'sappointment as Minister of Health, that the foundations were to be laid for the1962 Hospital plan,'6 a publication that finally marked government commitment toa significant programme of hospital investment.For those projects which did proceed the problems were not simply financial: low

NHS pay scales made architectural employment unattractive compared with privatepractice, whilst the private firms which consequently gained almost all the earlymajor commissions lacked up-to-date design guidance. Indeed, at a 1954 RoyalInstitute of British Architects (RIBA) conference on hospital design, one commentatorremarked, "With a few notable exceptions, the architect delegates seemed to feelthat they were not qualified to express opinions and had clearly come to theconference to listen rather than to talk."'17

10 'Hospitals: new programme', Architects' 16 See, for example, Charles Webster, TheJournal, 7 July 1955, p. 8. health services since the war: vol. 2, Government

1"Webster, op. cit., note 5 above, p. 344. and health care, the National Health Service12Op. cit., note 10 above. 1958-1979, London, HMSO, 1996. See also,'3 'Hospital building progress', Architect and Charles Webster, The National Health Service. a

Building News, 31 December 1958, p. 860. political history, Oxford University Press, 1998;14 'New hospitals: minister gives news', Ministry of Health, A hospital plan for England

Architect and Building News, 11 November 1959, and Wales, (Cmnd 1604), London, HMSO, 1962.p. 423. "''The architect and the doctor', Official

"A L Abel and W Lewin, 'Report on hospital Architecture and Planning, November 1954, p.building', Br med. J. (Supplement), 4 April 1959, 521.pp. 109-14.

23

Jonathan Hughes

Inter-war Development of Hospital Design

With the late start to hospital building after the War, British hospital design hadeffectively stagnated for two decades, given that those hospitals built under the war-time Emergency Hospitals Service (EHS) had typically been makeshift single-storeyhutted complexes. By contrast, the inter-war period had witnessed a varied output-from modest cottage hospitals to monumental urban hospital centres, across boththe voluntary (private) and local authority (public) sectors. It had also been a periodof fundamental change in hospital design, as modernist architectural thinking offerednew stylistic freedoms to the architect. At the same time, hospitals were growing insize and complexity, distributing the cost of expensive new diagnostic and therapeuticequipment over an expanding complement of beds and outpatient clinics, all ofwhich increasingly rendered medical architecture a specialist activity. This pro-fessionalization of hospital design was bolstered by the growing perception of thehospital as an effective machine a' soigner rather than some sordid hostel whereimpotent quacks simply presided over the lingering demise of their bedfast patients.The Architects' Journal stated the case bluntly in 1932: "Hospitals house sick people... Every sick person costs 8s. or 9s. per day, is earning nothing, and is a burdenon the community. Hospitals exist to put them right and turn them into the worldas economically as possible."'8 Clearly, the journal envisaged hospital architectsfacilitating this clinical process through efficient, modern hospital design. And it wasinpatients who were the first to witness the greatest changes as hospitals reconfiguredtheir wards in response to changing medical and social pressures.

Popularized by Florence Nightingale, the open ward of about thirty beds arrangedup and down an open room became a standard ward layout of the late nineteenth-century (Figure 1).29 Inpatient hospital care had traditionally been reserved for theless fortunate in society, as recipients of charity or relief under the Poor Law, andthere was little incentive for the authorities to cosset their charges (a situation oftenunchanged by the introduction of the voluntary hospitals' own contributory healthinsurance schemes). The design of these wards was part predicated on the miasmicconception of infection, which attributed disease to the noxious emanations andsmelly air thought to fester in ward rooms. The dissipation of these vapours was,therefore, crucial, necessitating high ceilinged wards cross-ventilated by windows oneach side (Figure 2), and arranged as a series of pavilions open to the sun and air.The advantages of the plan were not simply medical, for such a ward could easily

be supervised by a small nursing staff. For more extrovert patients the design possiblyfostered a spirit of camaraderie, whilst the constant distractions alleviated theboredom of a protracted stay in bed (indeed, such noisiness could shield personalconversations with clinicians). None the less, the open ward generally presented a

'8'Hospital specialization', Architects' Journal, London, Mansell, 1991; also Adrian Forty, 'The16 November 1932, p. 605. modern hospital in England and France: the

'9 See, for example, G Goldin and J D social and medical uses of architecture', inThompson, The hospital: a social and architectural Anthony King (ed.), Buildings and society: essayshistory, London, Yale University Press, 1975; on the social development of the built environment,Jeremy Taylor, Hospital and asylum architecture in London, Routledge & Kegan Paul, 1980, pp.England 1840-1914: building for health care, 61-93.

24


Figure 1: Plan of a typical Nightingale open ward, late nineteenth-century.

Figure 2: Guy's Hospital, London, open ward, not dated (early twentieth-century). Courtesyof King's College London.

lack of privacy, especially for seriously ill patients, for whom only one or two singleside-rooms might be provided. Furthermore, with few sanitary or day facilities,patients had little relief from the bedpan round and the ward environment. Nor did

25

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Jonathan Hughes

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the open ward facilitate the flexible allocation of beds between sexes; a half-emptymale ward would stay that way whilst an adjacent female one might be over-crowded.Finally, the Nightingale ward presented architectural problems; its high ceilingsgenerally militated against buildings taller than three or four storeys, whilst the spacerequired between adjacent ward blocks (to ensure the adequate penetration ofsunlight and fresh air) grew in proportion to their height.20For wealthier patients, the inter-war years witnessed the consolidation of the

hospital's position as the site of expert clinical treatment. The increasing efficacy ofsurgical techniques, building on nineteenth-century advances in anaesthetics andasepsis, rendered hospitalization not only more effective, but also more attractiveto those whose care had traditionally been effected at home. Able to provide theaseptic operating conditions necessary for modern surgery, voluntary hospitals couldnow generate income by offering fee-paying middle-class patients single rooms innewly-built annexes.

For the less fortunate, a major reappraisal of inpatient accommodation was alsounderway in Britain by 1930, prompting the subdivision of the wards of both localauthority and voluntary hospitals into smaller sections and placing beds parallelrather than perpendicular to the walls. Prototypes for such a layout could be foundboth in America and in the 1910 ward layout of the Rigshospital, Copenhagen(Figure 3)-a design apparently first employed in Britain in Percy Adams' 1929design for Southend Hospital. If Adams a principal of architects Adams Holden

20'Hospital planning and development', 21 For an account, see John Woodward, To doLancet, 1937, i: 225-8. the sick no harm: a study of the British voluntary

hospital system to 1875, London, Routledge &Kegan Paul, 1974.

26


& Pearson-had been converted, others remained unconvinced: the practice's Bir-mingham Hospital Centre design was rejected for its unconventional wards. Nonethe less, Adams incorporated the Rigshospital layout into his prototypical MiniatureHospital for the King Edward's Hospital Fund for London of 1933. Intended aspropaganda for the voluntary hospital sector, this 1/16th-full-size model typifiedprogressive design trends, with its solaria and smaller twelve-bed Rigshospital-stylewards subdivided with part-glazed screens.22 Compartmentalization (achieved eithervia subdivided open wards or smaller purpose-built bedrooms) was increasinglyaccepted by hospital architects during the 1930s in numerous though not all-projects, as at Elcock & Sutcliffe's Hertford County Hospital (1932-4) and BurnetTait & Lorne's Royal Masonic Hospital (1931-3). Indeed by the 1940s the openward could be declared by some to be out-of-date,23 and the victory of the subdividedward complete.24The abandonment of the miasmic theory of infection was an essential factor

underwriting these changes. Medical understanding of bacteriology and germ theoryhad rid epidemiology of its reliance on theories of noxious odours, and emphasizedanti-septic and subsequently aseptic procedures rather than cross-ventilation in thebattle against bacterial contagion. In response, during the 1930s, designers began tospecify hard non-absorbent internal surfaces and smaller bed bays with privacyscreens to counter and localize infection. The uncontrolled Nightingale ward flowof air was now thought simply to cross-infect surrounding patients. As the Architects'Journal noted in 1937:

The pavilion style, so characteristic of English hospital planning during the past sixty yearsor so was based on the theory of the aerial convection of infection. This is now recognisedas a fallacy, and the effect on hospital design is becoming apparent already. Hospitals will bemore compact, and will not necessarily be restricted in height; and the saving in money, time,and energy is certain to be considerable. Isolation hospitals are now things of the past. Thepavilion system may be retained in tuberculosis sanatoria, but even this is neither necessaryor certain.25

Yet, the role of sunlight and fresh air was far from discounted. Most notably,sunlight was shown to have direct therapeutic and anti-bactericidal properties; whilstin the treatment of tuberculosis and rickets light treatment became valued duringthe 1930s. As the Royal Institute of British Architects' 1933 report, The orientationof buildings, noted:

During the last few years an extraordinary and even revolutionary change has taken place inall countries in the general application, both by the medical profession and by the generalpublic, of the values of fresh air and light, particularly sunshine. The treatment of somediseases by exposure of the skin to the action of light, natural or artificial, has in a marvellously

22 The King's Fund miniature hospital, London, trends in hospital design', Architect and BuildingKing Edward's Hospital Fund for London, 1934. News, 27 June 1947, pp. 254-8.

23'Review of equipment and materials: the 25 A G Ogilvie, 'Today and tomorrow: thehospital ward', Architect and Building News, 28 medical view', Architects' Journal, 24 June 1937,June 1940, pp. 256-7. pp. 1094-8, on p. 1098.

24J Murray Easton and S E T Cusdin, 'Recent

27

Jonathan Hughes

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Figure 4: Comparison of ward designs and patient insolation from the Royal Institute ofBritish Architects, Joint Committee on the Orientation of Buildings, The orientation ofbuildings, London, RIBA, 1933. From Ronald Ward, The design and equipment of hospitals,London, Bailliere Tindall & Cox, 1949.

short space of time leaped from the obscure position of a somewhat contemptuously neglectedspecific to the status of one of the most valued and even invaluable weapons in the medicalarmoury.26

The report dismissed the Nightingale ward as clinically inefficient, since its envelopewas typically 60 per cent wall and allowed little direct light to fall on the patient'sbody. By contrast, the Rigshospital layout, with its wide picture windows (and only34 per cent solid wall), demonstrably increased both the quantity and the efficacyof patient insolation (Figure 4). Lionel Pearson's 1932 article 'Light and air in themodem hospital'27 had already established the principle, and was reiterated in theArchitects' Journal's 1937 hospitals issue.28 Hospital design could now offer medicine"an overwhelming improvement in efficiency"29 and modernist architecture, in par-ticular, exploited constructional technology to provide both the necessary structural

26RIBA Joint Committee on the Orientationof Buildings, The orientation of buildings,London, RIBA, 1933, p. 3.

27 Lionel Pearson, 'Light and air in themodern hospital', Architects' Journal, 16November 1932, pp. 609-19.

2 Ogilvie, op. cit., note 25 above.29RIBA Joint Committee, op. cit., note 26

above, p. 14.

28

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Figure 5: Paimio Sanatorium, Finland, by Alvar Aalto, 1929-33.From Architects' Journal, 16 November 1932.

forms and the appropriate connotative allusions-its cantilevered balconies likecruise liner decks; its simple, whitewashed geometric forms evocative of order andhygiene. Drawing on such continental European precedents as Alvar Aalto's PaimioSanatorium (1928-33, Figure 5) and Bijvoet & Duiker's Zonestraal Sanatorium(1928), progressive British designers offered schemes which challenged establishedapproaches to the architectural styling of the hospital. One of the most notableaccomplishments of the new vanguard was Pite Son & Fairweather's Sully Hospital,a tuberculosis sanatorium near Cardiff (1931-7), in which an expansive, low-riseplan was elaborated with cubic white blocks and balconied terraces lined withstretches of glazing. Yet, it was not sufficient to provide an architectural illusion ofefficiency, for there was still much to be done within the building. Most notably,clean and dirty procedures could be more systematically separated within wards,whilst the treatment of patients could be removed altogether from bed areas. Thesedevelopments were to await the end of the War and the researches into hospitaldesign marshalled by the Nuffield Provincial Hospitals Trust.

29

.%6

Jonathan Hughes

The Nuffield Provincial Hospitals Trust andThe Development of Hospital Design

The Nuffield Provincial Hospitals Trust (NPHT) was but one of Lord Nuffield'scharitable bodies established in advance of the 1943 Nuffield Foundation.30 FormerlyWilliam Richard Morris (1877-1963), Lord Nuffield had made his fortune frommotor manufacturing (Morris Motors) and subsequently dispensed large amountsof it to charity. Medical causes were major beneficiaries-variously attributed to hisunfulfilled desire to be a surgeon, his hypochondria, and the need to ensure the goodhealth of his workforce (local hospitals being recipients). Founded in December 1939with one million shares in Morris Motors, the official purpose of the NPHT was"the co-ordination on a regional basis of hospital and ancillary medical servicesthroughout the Provinces".3' Created partly to prevent the breakdown of hospitalservices which the War was expected to entail, it was but one of numerous variously-motivated inter-war attempts to integrate the ill-coordinated collection of private,public and charitable healthcare facilities and insurance systems.32 Yet it was notuntil the establishment of the state-controlled Emergency Hospital Service (EHS)with the outbreak of war that a comprehensive hospital organization based on theeleven Civil Defence regions forced co-operation between the various parties.33The EHS's geographical pattern of organization-reworked to provide a teaching

hospital in each region was to form the basis of the NPHT's 1941 proposal for are-organized post-war health service.34 Indeed, the NPHT subsequently undertookseveral hospital surveys with the Ministry of Health, highlighting the country'sinadequate healthcare facilities and staffing.35 The creation of the National HealthService signalled the realization of the NPHT's original raison d'etre and it promptlyrealigned itself towards research into various medical fields and, from 1949, healthcentre and hospital design, initially under John Madge and then architect Richard(later Lord) Llewelyn-Davies (assisted by John Weeks, later Llewelyn-Davies'sbusiness partner).A series of studies, reports and building projects followed, including health centre

schemes at Harlow (1952) and Corby (1954), a Geriatric Day Hospital at Oxford(1958), a small hospital project at Mignot Memorial Hospital, Alderney (1960), as

30 For a general history of the NPHT seeGordon McLachlan, A history of the NuffieldProvincial Hospitals Trust 1940-1990, London,Nuffield Provincial Hospitals Trust, c. 1992.

3' NPHT, A report on the activities of the Trust1939-1948, Oxford University Press, 1949, p. 9.

32 For example, the Ministry of HealthConsultative Council on Medical and AlliedServices, 1920 (the Dawson Report), the 1937report of the Voluntary Hospitals Commissionsfor the British Hospitals Association (the SankeyReport), the Planning and Economic PolicyGroup's 1937 Report on the British health services,and the BMA's 1938 report, A general medicalservice for the nation.

"The Emergency Hospital Service (1939-45)built over 100 hospitals including several 600-bedand one 1,000-bed hutted hospitals.

34 NPHT, A national hospital service: amemorandum on the co-ordination of hospitalservices, Oxford, NPHT, 1941.

35 For example, Ministry of Health, Hospitalsurvey: the hospital services of London and thesurrounding area, London, HMSO, 1945. For arecent history, see Martin Powell, Evaluating theNational Health Service, Buckingham, OpenUniversity Press, 1997.

30


well as influential reports into laboratories (1961) and children's hospitals (1963).36The Trust's outstanding contribution (undertaken with the University of Bristol)was its Investigation into the functions and design of hospitals, published in 1955.37The multi-disciplinary team availed itself of the latest international design guidance,questionnaires, time and motion studies and research to reconsider hospital designfrom first principles, ranging over nursing routine, medical technique, architecturaldesign and their financial implications.38 Whilst addressing the whole hospital, it wasthe research into ward design which had the most immediate and enduring impact.Consolidating the trend away from the Nightingale ward plan and dismissing themiasmic theory of infection, the team argued instead for the sub-division of theward to combat bacterial cross-infection. Statistics suggested that 10 per cent ofinpatients acquired an infection whilst in hospital, and that the problem was gettingworse as strains of staphylococcus were growing increasingly resistant to antibiotics.39The architect could control neither the source nor the recipient of the infection, butcould affect the clinical environment by sub-dividing wards, providing segregatedtreatment areas for dressing wounds, and installing air-conditioning to prevent thespread of bacterially contaminated air. Equally, the proposals increased patientprivacy and thereby enabled the allocation of beds between sexes and clinicalspecialities within the ward, fostering a more flexible, and managerially more efficient,utilization ofbeds albeit, notably, at the expense ofnursing ease ofpatient supervision.The Nuffield studies emphasized the early ambulation of patients, a regime which

had been found during the Second World War to speed recovery, cut inpatient stayby up to half, and increase the throughput of cases (estimated in 1951 to be 10-20per cent higher).40 Of those not bedfast it was estimated that most would requiretoilets, whilst half would need a day space- amenities often lacking from theNightingale plan.41 Furthermore, the team suggested that medical need necessitatedfour single rooms per sixteen beds-considerably more than previously estimated.42A further constraint on the ward layout was imposed by the need to economize onscarce NHS nursing staff; time and motion studies were employed to measure the

36Nuffield Foundation: Division forArchitectural Studies, The design of researchlaboratories, London, Oxford University Press,1961; and, idem, Children in hospitals: studies inplanning, London, Oxford University Press, 1963.The Division took over the NPHT's architecture-related research between 1954 and 1960, againunder Llewelyn-Davies.

37NPHT, Studies in the function and design ofhospitals, London, Oxford University Press, 1955.

38The team included a physician, nurse, field-work organizer, historian, accountant andarchitect, assisted by 39 time-study engineers,architects and research assistants.

3 In 1945 10 per cent of staphylococcus wasresistant to antibiotic, by 1960 it was 90 per cent(T Somerville, 'The control of hospital infection',Architects' Journal, 7 July 1960, pp. 9-11).

40 Early ambulation was first expounded forabdominal surgery in 1899 by Emil Ries in the

Journal of the American Medical Association,where he noted the "obvious" economic benefitsto the US public of $1bn from the early return ofpatients to work. Subsequently, in the 1940s, USsurgeon Daniel Leithauser reported that earlyambulation halved inpatient stay (J W DGoodall, 'Early ambulation: a survey of hospitalpractice', Lancet, 1951, i: 43-6; also DanielLeithauser, Early ambulation and relatedprocedures in surgical management, Springfield,Ill., Charles C Thomas, 1946, esp. pp. 217-19).

4' Goodall, op. cit., note 40 above.42J W D Goodall, 'Single rooms in hospital:

estimate of the medical need', Lancet, 1951, i:1063-5. Four single rooms per sixteen beds wouldbe sufficient to meet 82 per cent of medical need(i.e., infective cases, infectable cases, the dying/seriously ill, "nuisance cases" (owing to theirmedical condition), and special attention cases).

31

Jonathan Hughes

Figure~~~~~~~~~~~~~~ ~6:LakilHoptl Grenck Nufiel Prvnca Hopial Trst(Richr Llewez wslyn-i

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Studies in function anddesoM.O.ndU ity ress, 195. C

Figure 6: Larkfield Hospital, Greenock, Nuffield Provincial Hospitals Trust (Richard Llewelyn-Davies, John Weeks, et al.), 1951-6. Plan of ward. From Nuffield Provincial Hospitals Trust,Studies in function and design of hospitals, London, Oxford University Press, 1955. Courtesyof Oxford University Press and John Weeks.

distances walked by nurses and suggested that their time could better be utilized ina more compact ward layout than the Nightingale plan. The task faced by theNuffield team, then, was to design a ward which could accommodate an increasingnumber of sanitary, day and ancillary rooms, as well as sub-divided bed bays tominimize cross-infection within a more compact layout, and still be capable ofefficient patient supervision.The Nuffield programme saw the completion of two experimental ward blocks at

Larkfield Hospital, Greenock (1951-6) (Figure 6) and Musgrave Park, Belfast(1956-9). The Larkfield design provided two 32-bed wards in a two-storey blockattached to the main hospital. The wards were split into two units of sixteen beds,each with its own nurses' base and shared service rooms between. Following theteam's proposals, the design incorporated smaller, four-bed bays, additional WCsand single rooms, a separate treatment room and a patients' day room. This planformed the basis of the later forty-bed Musgrave Park unit, with patients dividedbetween two nurses' bases.The team still aimed for the natural illumination of the ward, although by 1954

it was felt that "From the purely medical viewpoint there are very few conditionsfor which sunshine is specifically needed".43 Indeed, the post-war treatment of suchdiseases as tuberculosis with streptomycin (rather than light therapy or surgery) andthe diminishing length of inpatient stay (partly due to early ambulation) were allcontributing to lessen the therapeutic necessity of sunlight. For architects, convenienceof planning was now the overriding design consideration, and so balconies, solariaand other such features were rapidly to disappear from post-war hospital architecture.The Nuffield studies remained the only British source of modern hospital design

43 Davies, op. cit., note 3 above.

32


throughout the 1950s, bolstered by Nuffield-run hospital design conferences at theRoyal Institute of British Architects in 1954 and 1958, and a stream of Nuffieldpublications. Other sources included Ronald Ward's 1949 Design and equipment ofhospitals, and the 1947 American text Hospitals: integrated design by IsadoreRosenfield; each provided alternative guidance but lacked the immediacy andauthority of the Nuffield work. The involvement of the Ministry of Health in hospitaldesign was both late and low key; the Ministry's first Hospital building bulletin onoperating theatres was not published until 1957," and it appeared to the architecturalprofession that the Ministry was "trying desperately to recoup an impossible situ-ation".45 Indeed, only in 1959 did the Ministry gain a formal "Architect's Branch"under William Tatton Brown (modelled on the influential Ministry of Educationschool design pattern"), and only in 1961 did publication begin of the Hospitalbuilding notes, offering guidance on individual departmental design, just as thehospital building programme was finally being substantially enlarged under EnochPowell's 1962 Hospital plan.47 In the meantime, the Ministry relied on the Nuffieldwork, for example collaborating in 1960 on hospital design courses at the RIBAand Worcester College, Oxford. With a growing number of major projects underconsideration, architects also needed to consider the architectural form of the wholehospital, and it was the tower block which first offered a form for the modernhospital-its employment not only giving designers a means of obtaining much-heralded operational economies, but also the opportunity of endowing the hospitalwith a symbolic architectural modernity.

The "Matchbox on a Muffin"

The overt display of architectural modernity was a seductive lure for many post-war hospital designers; how better to express the modernity of the medical care tobe found inside than through the employment of a legibly modern architecturalform? If medical science was a progressive, modern discipline (with an ever-wideningrange of treatments and therapies), architecture too had a growing range of moderntechnologies and styles at hand. That the hospital should simultaneously serve andutilize the two seemed, to many architects, both logical and imperative.The first major post-war hospital projects took place against the backdrop of the

final years of the Macmillan administration and the consumer and property boomsreordering life in Britain's cities. If, at times, the reorganization of Britain's socialinfrastructure occurred almost by stealth, the same could not be said of the re-construction of the nation's cities. New motorways and ring-roads were creatingfast, modern transportation networks, which architects furnished with modernistoffice and housing blocks indicative of a country belatedly modernizing its physicalenvironment. The office tower block enjoyed special prestige, both as the site of an

" Ministry of Health, Operating theatre suites 46 See Andrew Saint, Towards a social(Hospital building bulletin 1), London, HMSO, architecture: the role of school-building in post-war1957. England, London, Yale University Press, 1987.

" 'Hospital programme', Architects' Journal, 47 For a further discussion see Webster's21 July 1960, p. 91. publications, op. cit., note 16 above.

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Figure 7: Lever House, New York, Skidmore Owings & Merrill, 1952.

essentially modern form of work, and also through the "machine-age" aestheticdeployed in its design. Office work was white-collar, respectable and clean, all themore easily elided with the image of a modern, democratic economy than themanufacturing and heavy industry so central to Britain's nineteenth-century economy.Nor was there much hesitation in adopting the paradigm of post-war office blockdesign demonstrated by New York's Lever House of 1952 (by Skidmore Owings &Merrill (SOM), Figure 7) where a simple tower of office accommodation rose froma similarly geometric plinth of ancillary accommodation, the latter's horizontalitymaintaining the street line and offering a counterpoint to the slender verticality ofthe tower. Britain first gained its own version of Lever House in 1959: Castrol House(on the Marylebone Road, London) by Gollins Melvin & Ward (GMW) was a pareddown imitation, yet it was rapidly to be replicated across the country. Indeed, GMWhad a high reputation for modern office architecture, and a 1956 Architectural Reviewcritique of their work suggested approvingly (and revealingly),

It is efficient, and it comes from an office that has set itself to be efficient, commercial andmodern ... it can only be a matter of years before [buildings like Lever House] becomecommonplace. For they are not difficult to design they are the product of a system of exactthinking and meticulous detailing ... we should hail the appearance of the first completely

34


anonymous piece of machine architecture to appear in London this century ... it is notpretending to be a palace, or a temple, or even to be a work of great architecture."

It was not simply the air of efficiency and modernity suggested by the sleek,shining surfaces of Lever House's glazed walling which were of note; the buildingalso dramatized the split between repetitive, speculative office areas and fixed,irregular ancillary areas through their separation into an upper office tower slababove a lower podium of service and support accommodation. Other modernist (andnon-modernist) architects had already effected similar manoeuvres, yet here thestatement was redressed in a refined drapery of polished glass and metal. The messagewas clear enough: no longer did all the building's functions have to be shoe-hornedinto a symmetrical, classicized block: those activities which required more spacecould extend within the limits of the lower block, whilst the sideways-on tower couldrupture the once inviolate street elevation. For many modernists the tower-on-podium promised an ideal marriage of function, science, economics and art. It isnot surprising, therefore, that by the early 1960s this form had taken its place asorthodox hospital design practice, under the sobriquet "matchbox on a muffin".That this was possible depended on two developments, namely the acceptance ofwards stacked in a tower, and a rethinking of the way in which people, goods andservices were to be moved around the hospital, ushering in a range of mechanizedsystems of communication.

The Genesis of the Tower-Block Hospital

The Nuffield Studies had shied away from suggesting an architectural form forthe whole hospital. However, the tower-on-podium offered a neat conceptual andaesthetically acceptable solution, with standardized ward units stacked over a matof flexible, expandable diagnostic, outpatient and ancillary departments. This designwas underwritten by promises of efficiency gains from the centralization of ancillaryprocedures in the lower block. The precedents to which British architects looked forguidance followed a clear pattern, which drew on British inter-war hospital towers,the large wartime hospitals built in neutral European countries, and finally therationalized designs of post-war American hospitals. A crude architectural patternalso emerges, beginning with the inter-war attempts to squeeze all the variousirregular departments into a solid, unbroken classicized facade, moving on to thedispersal of functions into linked parallel blocks, and concluding with the conceptualsimplicity of the modernist tower-on-podium. In practice, when British architectssought to adopt the model-and not all did-the results rarely achieved the formalclarity of the ideal, given the reluctance or inability to centralize functions fully, andthe problem of reconciling all the necessary departmental adjacencies with such adesign.

Clearly, designers had long built high on tight urban sites, yet during the 1930sarchitectural flexibility remained constrained by the extent to which they dared

48'Commercial, dead or alive', ArchitecturalDesign, August 1956, p. 243.

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Jonathan Hughes

Figure 8: Middlesex Hospital, Fitzrovia, London, Alner Hall, 1926-35.(Photo: Jonathan Hughes.)

subvert the formal coherence of traditional, classicized, architectural style with themultifarious demands of the modern hospital brief. At both the Middlesex Hospital(1926-35, Figure 8) and Gordon Hospital (c. 1948), architect Alner Hall had soughtto accommodate all the various hospital functions within symmetrical, ordered formsmaintaining a unified and classicized fa9ade. Similarly, Adams Holden & Pearson'sWestminster Hospital (c. 1938) displayed an unwillingness to transgress the demandsof its stripped-down classicized fa9ade.European Modernists had little such reticence: most notably-for British hospital

designers-Alvar Aalto's Paimio Sanatorium (1928-33, Figure 5) offered a modelfor architects seeking a prototypical modernist tower form. Reproduced in nearlyall the British inter-war pro-Modernist architectural texts, Paimio manifested notonly a progressive ward design, but also offered the bold vertical configuration of

36


Figure 9: Beaujon Hospital, Clichy, Paris, Jean Walter, Plousey & Cassan, 1935. From GustafBirch-Lindgren, Modern hospital planning in Sweden and other countries, London, Constable,1951.

wards which was to underwrite 1950s design. Yet Paimio was a tuberculosis san-atorium, with a narrow range of functions and it was to other precedents that post-war British architects turned for guidance. The Beaujon Hospital (Clichy, Paris, byJean Walter, Plousey & Cassan, 1935, Figure 9) constituted a remarkable precedent-its 1,100 beds ranged in four south-facing, thirteen-storey, ward blocks sited alonga spine of service accommodation. At its base a lower, linked group of outpatient,medical and surgical blocks centralized the diagnostic and major clinical functions.More importantly, Switzerland and Sweden, both neutral during the War, had

maintained hospital construction during the 1940s. Each viewed rationalization andcentralization as integral to a modern, effective health service the resulting largevertical hospitals becoming sites of pilgrimage for British architects after the War.49Basel's Burgerspital (by Vischer, Braunig, Baur & Durig, c. 1945) was especiallynotable, its 660 beds placed in a long, eight-storey ward block with a parallel three-storey diagnostic, surgical and outpatient block. Similarly, Stockholm's immense,

'9 Stuart Gray, architect of New Guy's House, Building News, 8 September 1955, pp. 289-97. WGuy's Hospital, noted that the Caroline and F Howitt, architect of the new St Thomas'sSouth Hospital, Stockholm, the University Hospital likewise recalled extensive EuropeanHospital, Zurich, and the Burgerspital, Basel, reconnaissance visits (in conversation with thewere all much visited (Stuart Gray, 'Studies in the author, December 1993).functions and designs of hospitals', Architect and

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Jonathan Hughes

A' *1

Figure 10. Soder Hospital, Stockholm, Sweden, Hjalmar Cederstrom, 1938-43. From GustafBirch-Lindgren, Modern hospital planning in Sweden and other countries, London, Constable,1951.

Figure 11. St Lo Hospital, Normandy, France, Paul Nelson, c.1949. From ArchitecturalReview, March 1949.

1,200 bed Soder Hospital (Hjalmar Cederstrom, 1938-43, Figure 10) was lauded byBritish designers as a masterpiece of standardization and hospital organization andplanning.

It was, however, American thinking which ultimately propagated the "matchboxon a muffin", demonstrated at Paul Nelson's 400-bed St Lo Hospital (Normandy,c. 1949, Figure 11). The Franco-American architect was well placed to assimilate

38


Figure 12: Cover of Architectural Review, June 1965, with Gordon Friesen flow chart.

both the Taylorist approaches prevalent in America,50 and the modernist sensibilityof inter-war Europe. Nelson's unrealized 1932 project for the Cite Hospitaliere deLille5" had already deployed ward towers over a lower block, a solution to berepeated at St Lo, where the outpatient and medical services were placed in a lowermat, below an eight-storey ward block. Its functions were clearly separated andarticulated, with circulation vertically centralized at the core of the building.The industrialization of this model was subsequently advanced in a series of ten

hospitals completed in 1956 across Virginia and Kentucky to a brief prepared byhospital administrator Gordon Friesen for the United Mineworkers of AmericaWelfare and Retirement Fund. Friesen's work sought to exploit Taylorist possibilitiesto the full, removing the maximum number of functions from the ward to remote,centralized departments where their work could be more easily surveyed, controlledand rendered more efficient through the application of work-flow studies, jobspecialization and mechanization (Figure 12). The "matchbox on a muffin" formwas an ideal one in which to plan a vertical central core of mechanized distributionsystems rising from a central dispatch centre located in the podium serving the wards

5 Edward Morman (ed.), Efficiency, scientific 5 'Health city of Lille, France', Architecturalmanagement and hospital standardization: an Record, 1935, June, pp. 408-9; also, Terence Rileyanthology of sources, New York, Garland, 1989. and Joseph Abram, Thefilter of reason: the work

of Paul Nelson, New York, Rizzoli, 1990.

39

Jonathan Hughes

Figure 13: Illustration of ward supply centre, Gordon Friesen, c. 1962. From George H Bell(ed.), Hospital and medical school design, Edinburgh and London, E & S Livingstone, 1961.

above (Figure 13). All sterile requirements were to be provided from a Central SterileSupply Department (CSSD) via lifts; similarly catering needs, with meals preparedin a single, whole-hospital kitchen and distributed to the wards via a "trayveyor"-theused utensils being returned to a central wash-up facility. There were to be no storagecupboards for clean utility; wards would be provided daily with a trolley-load ofsupplies. Pneumatic tubes were to deliver x-rays, specimens and notes around thebuilding, economizing on porterage and delivery time. As Friesen put it, "In an ageof mechanization, logic dictates that some of the production methods of industryshould be applied to certain areas of the hospital."52Three of Friesen's ten Mineworkers' schemes were general hospitals,53 with Harlan

Hospital most insistently adopting the pristine cubic forms of SOM's Lever House.John Weeks noted in 1959, "The atmosphere is very like that of an industrial concernand indeed Americans often talk of a 'health plant' instead of 'hospital"', addingthat Friesen's work was "undoubtedly the most fascinating development since theWar in the United States".54 Likewise, W J Jobson, Chief Architect of the Oxford

52Gordon Friesen, 'Mechanization and 'John Weeks, 'Developments in the Unitedhospital design', Architectural Design, January States of America', RIBA Journal, January 1959,1961, pp. 7-9. pp. 83-7.

5 Beckley by Isadore Rosenfield, Williamsonby York & Sawyer, and Harlan by Sherlock,Smith & Adams.

40


Regional Hospital Board, studied hospital business, its mechanization and its effecton the nursing floor in America-his findings were published alongside an articleby Friesen in a 1961 issue of Architectural Design devoted to 'Mechanization andhospital design in Britain', edited by Weeks.55The difference with British practice was most striking in the administrative

organization of American medical provision, centred on a more profit-driven,meritocratic, managerial structure, rather than a nationalized system still dominatedby prominent medical personalities and an ingrained class structure. Yet Britain waschanging, and the American model was not to be lost on hospital architects sweptalong by the rhetoric of Harold Wilson's white-hot "scientific revolution". LikeWilson's new Britain, the new NHS hospital was not just to be modem, but moremeritocratic, mechanized and efficient. This perhaps was the hospital in which Bevanhad, in 1946, hoped to expire-a hospital in which efficiency and quality of carewent hand in hand. Automation promised to make this vision a reality, as a 1956Department of Scientific and Industrial Research report had noted: "Like otheradvances in technique, [automation] will increase efficiency and should, therefore,reduce costs."56 Nor was it necessarily an over-optimistic vision. British commentatorshad noted the centralized laundries, kitchens and CSSDs in continental Europeanhospitals soon after the War, prompting the NPHT to initiate research into CSSDs.Indeed, the trend towards centralization may be noted in Britain from the 1930s,just as the development of the sub-divided ward, suitable for stacking in a tower,was likewise underway before the War. As the Architects' Journal had noted in 1937:

... there will be a definite trend towards higher buildings ... the advantages gained bycentralized services are obvious, and vertical plumbing and service stacks can simplify whatis usually a very complicated series of installations. It seems likely also that the higherbuilding of five to eight storeys would be cheaper in maintenance costs-assuming equalaccommodation.57

The majority of the large post-war British hospital schemes adopted some variantof the tower-on-podium form, whether or not site constraints demanded thatthe architect build upwards rather than outwards. The logic of rapid verticalcommunications, the constructional simplicity of repetitive ward floors, and theimpressive architectural statement of the high-rise tower combined to make the"matchbox on a muffin" an appealing design solution for the modern hospital.Indeed, it was only Powell & Moya's Wexham Park Hospital, Slough (1955-66),which, during the 1950s, consciously, and with much publicity, dared to propose apredominantly single-storey whole-hospital design-a strategy which however would

55W J Jobson, 'Hospital business, its 57D R Harper, 'Today and tomorrow: themechanization and its effect on the nursing floor', architectural view', Architects' Journal, 24 JuneArchitectural Design, January 1961, pp. 12-16. 1937, pp. 1099-1104.

56 Department of Scientific and IndustrialResearch, Automation, London, HMSO, 1956,p. 80.

41

Jonathan Hughes

Fiur1. Aitngl Hoptl Lododer, Yok Roebr & Madl, 1949 60.

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42


Figure 15: Hull Royal Infirmary, Hull, Yorke Rosenberg & Mardall, 1957-65.

Standing alone in an expanse of fields, it was clear that lack of space had not dictatedthis design: the twelve floor L-shaped tower housed wards in one wing and diagnosticand treatment facilities in the other, with outpatient clinics occupying the largerground floor. It was not until 1957 that Yorke Rosenberg & Mardall wholeheartedlyadopted the "matchbox on a muffin" at Hull Royal Infirmary (1957-65, Figure 15),where the Altnagelvin L-shaped plan was replaced with a simple block of wardsover a lower mat of ancillary, diagnostic and outpatient facilities.Such a development of design strategy was not uncommon, as architects began

to refine their schemes. Indeed, of the major projects announced in the late 1950s(see notes 12 and 13 above) nearly all placed their wards in a tower over ancillaryaccommodation, although few achieved the architectural simplicity of Yorke Ro-senberg & Mardall's "clean sliced cliff'60 at Hull, and several opted for chains ofmedium-rise towers to house all the ward accommodation. None the less, otherswould soon follow suit-for example at Barking, London (North East MetropolitanRegional Hospital Board, 1963-7) and Fazakerly General, Liverpool (LiverpoolRegional Hospital Board, c. 1965). Such a transition towards the "matchbox on amuffin" may be traced through two early post-war projects at London's Guy's andSt Thomas's hospitals, schemes which demonstrate how the tower-block form wouldnot always be achieved without concerns over the architecture or the programme ofthe modern hospital.

6' Philip Larkin, 'The building', in Highwindows, London, Faber & Faber, 1974.

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Jonathan Hughes

An Uneasy Transition: Guy's Hospital

Founded in 1724 in Southwark, Guy's Hospital became not only a major Londonhospital, but also a medical school of great repute, bringing with it a series ofarchitectural accretions over two centuries. Yet, by the 1930s, the inadequacy ofsome of its accommodation-as old as the institution itself-was readily apparentand the possibility of rebuilding was considered. Its subsequent reconstructiondemonstrates not only how designers sought to cope with the problems of the largevertical hospital, but also how architecture could signify positive and negative aspectsof the modern world. Indeed, the first post-war scheme-New Guy's House-evidenced a reluctant modernity symptomatic of a deep-seated anxiety over theappropriateness of modern architectural form.

In 1936 the rumoured demolition of Guy's House-the spiritual home of theHospital as part of a scheme to rebuild the surgical facilities brought a livelydefence of the 1725 quadrangle. Articles in the Hospital's Gazette made plain thefear that rebuilding would be underwritten by a pernicious modernist functionalism,and indicated the ease with which commentators could align architectural designand a Taylorist approach to work study with one another:

... the tradition of service and teaching is not going to be in anyway improved by thedemolition of what is fine and beautiful in the Hospital; rather it will suffer, for in these daysof hustle and bustle and so called efficiency, when values of things are judged by whetherthey will save one a few minutes' or seconds' work, it is good to have a reminder that ourforerunners with no labour saving devices at their disposal could still find time to set storeby the fine exterior to their Hospital, which exterior was in some measure a reflection of thequality of their minds.6'

The hospital architect, William Walford, offered a ludicrous compromise retainingthe two side wings and the central facade of the original building, with the newaccommodation directly above in stripped-down classical style (Figure 16). Theproposals were considered inadequate and were shelved with the onset of War.However, with the bombing of the Hospital during the Blitz which destroyed theeast wing of Guy's House, the attractions of rebuilding were once again evident andin 1942 a post-war Planning Committee was established. Given Walford's impendingretirement, Alner Hall, of Young & Hall (architects of the recent Middlesex Hospital)was appointed in 1943 to prepare plans for a major rebuilding programme. Mean-while, the Clerk to the Governors, Bertie Lees-Read, and the Treasurer, J EHumphrey, recognized the opportunity for the expansion of the Hospital ontobombed land to the east, Great Maze Pond, and embarked on a twelve-year missionto purchase the site. Hall's first plans were produced in 1944, providing for a 1,000-bed hospital in one main, and one smaller block, necessitating the demolition ofnearly everything on the site (Figure 17). However, the main block was deemed toprovide impractical inter-departmental links and Hall redesigned the accommodationfirst in smaller units and subsequently as a snowflake-shaped hospital utilizing the

61 'Passim', Guy's Hospital Gazette, 18December 1937, pp. 519-20.

44


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t:4, n.j iS jId

Figure 16: Guy's Hospital, London, proposal for rebuilding Guy's House, William Walford,1936. Courtesy of King's College London.

whole site (Figure 18). This required the demolition of Guy's House, and foresawthree spokes radiating from a central tower, further splitting into three ward unitseach comprising Guy's traditional L-shaped 20-bed open ward with five single rooms.The administrative upheaval occasioned by the inauguration of the NHS briefly

curtailed any rebuilding plans. With a change of heart over the fate of the quadrangleand the September 1949 Ministry decision that hospitals be limited to 800 beds forcivil defence reasons,62 the "snowflake" plan was recast in similar form in 1951,albeit restricted to the site east of Great Maze Pond. Hall was now aided by architectPaul Burt, of the American firm Fugard, Burt, Wilkinson & Orth which had designedthe Wesley Memorial Hospital in Chicago Burt being deemed to have additionalinsight into the circulation and planning problems of a large and tall hospital. Theproposed exterior of the building provoked criticism, its brick and stone claddingprompting negative, if contradictory, responses. One reader hoped "that any plansfor rebuilding Guy's will not sacrifice beauty for utility", and noted that "there is adeplorable tendency nowadays to build awful structures ... uncompromisinglyhideous, and emanating, I believe, in the first place from America."63 Alternatively,

62 Bertie Lees-Read, 'The new Guy's', ibid., 22 63 G Dunderdale, 'Correspondence', ibid., 24October 1949, pp. 327-8. March 1951, p. 124.

45

Jonathan Hughes.ml-..I., ...

.

Figure 17. London, Guy's Hospital, rebuilding scheme, Alner Hall, 1944. Courtesy of King'sCollege London.

a Gazette reader with more progressive architectural taste lamented, "How sad thata great hospital, so very much in the van in matters medical and surgical, shouldallow itself to be so lamentably in the rearguard architecturally."'M Indeed, in oneattack on the architect's "Georgian" fa9ades there came the suggestion that Hallmight profitably look at the work of modern architects Frank Lloyd Wright andEric Mendelsohn:

If ever buildings require to be "functional", hospital buildings are such. Guy's is not acollection of individual homes under one roof, and therefore cannot be expected to look likeDolphin Square, as suggested by the models. On the contrary, Guy's is a humanistic factory,and cannot afford to look like anything but what it is. This is not a matter of taste, whichnotoriously is not debatable, but of efficiency, which is a matter of economy of means toobtain service and amenity.65

Hall's 1951 "snowflake" design was abandoned in late 1954 due to financial andtown planning obstacles, and Ministry objections to the commitment of the Hospitalto such a singularly large scheme.66 Given Hall's deteriorating health, new architects

'ARIBA, 'Correspondence', ibid., 29 66Bertie Lees-Read, 'The planning andNovember 1952, p. 466. erection of New Guy's House', New Guy's House,

65A Thompson, 'Correspondence', ibid., 23 commemorative brochure, 1961, pp. 19-23.December 1944, p. 283, my emphasis.

46


...............................................................................

Figure 18: London, Guy's Hospital, "Snowflake" rebuilding scheme, Alner Hall, 1951. Courtesyof King's College London.

were appointed, and by 1957 the Minister of Health could announce the rebuildingof Guy's surgical block to provide new operating theatres and 378 beds.67 The blockwas to be built on the newly acquired land and to stand alone yet be capable ofassimilation into a later redevelopment plan; as such it was to be twelve storeys highto minimize its footprint and offer the greatest scope for later planning.The new architects were Watkins Gray, a practice which had made its name abroad

designing hospitals in the West Indies following the firm's winning entry in the StGeorge's Hospital, Hyde Park Corner, London, competition just before the outbreakof War. The firm had been founded in 1903 in Bristol by William H Watkins(1878-1964) and, unswayed by modernist dogma, deployed styles and mannerismsas applicable. It expanded on lucrative commissions for shops, offices, public housesand, in particular, cinemas. Watkins' later partner, Stuart Gray (1905-1998) joinedthe practice briefly to work on a cinema commission, before leaving to join AdamsHolden & Pearson, working under Lionel Pearson on the designs for the newWestminster Hospital (1938-9). Poached back by Watkins to open a London officein 1936, an initial surfeit of work rapidly disappeared and prompted them to enter

67 'Passim', Guy's Hospital Gazette, 27 April1957, p. 171.

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Jonathan Hughes

0

Figure 19: Guy's Hospital, New Guy's House, London, Watkins Gray, 1955-61. Plan of wardfloor. From Newl Guy's House, commemorative brochure, 1961.

competitions. Drawing on his work with Adams Holden & Pearson, Gray formulatedthe prize-winning design for the 1938 St George's Hospital competition. The decisionproved controversial not least to modernists who saw little of merit in Gray'smonumental, Edwardian, stripped-down classicism. However, for the practice thecompetition was to prove a springboard on to other projects in the Caribbean andAfrica.

Gray's plan for the new surgical building at Guy's (Figures 19 and 20) retainedthe L-shaped open wards of Hall's scheme, justified against the Nuffield-backedtrend for compartmentalized wards since, as the architect declared, "the additionalburden on the nurses, which such small wards cause, was not justified by economicand social circumstances and because there seemed little evidence that patientspreferred them".68 The seven narrow ward floors on the upper storeys, with theoperating theatre and other accommodation on the ground, first and second floorsextending out from the rear elevation (not visible in Figure 20), provided a contrastbetween the brick-faced ward floors above and the framed operating floors below,thereby formalising (albeit with some reticence) the split between the tower and thenotional podium elements.News of the £2.25m scheme was greeted with enthusiasm. Press commentators

were captivated by this "semi-skyscraper", noting that it "should be the tallest andcertainly the most up-to-date hospital in Great Britain".69 The sentiments wereechoed upon the building's opening in 1961, the Evening Standard declaring "If onlythey were all like this!",70 whilst the Illustrated London News remarked, "The new

68 Stuart Gray, 'Description of architectural Hospital, London', Builder, 27 September 1957,features', Newt Guy: Hou.se, comnumemorative p. 529.brochure, 1961, pp. 24-6. 70 F Entwistle, 'If only they were all like this!',

69 'Guy's rebuilding begins', The Times, 21 Evening Standard, 23 October 1959.September 1957, p. 4; 'Rebuilding of Guy's

48


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Guy's House, near London Bridge, is the 'last word' in modern surgical science".71The provision of piped medical gases, bed-side telephone points and washbasinsbetween beds were all seen as advances, as was the CSSD. However, detractorsseized upon the "old-fashioned" open wards, and initiated correspondence in TheTimes, with Dr Stark Murray declaring the block "obsolete before it was ever puton paper and if we follow it and perpetuate open wards, British hospitals will, inspite of all the electrical and electronic devices, remain obsolete".72 Amongst itsfaults, critics noted that the unsatisfactory entrance to the ward passed the sluiceand the very sick in the single rooms; whilst the patients' day room was distant. Theresulting debate on the merits of the building, like the King Edward's Hospital Fundevaluation of it in 1963,73 proved inconclusive, although the Hospital subsequentlyadopted sub-divided wards in its next phase of rebuilding (Guy's Tower, WatkinsGray, 1963-76). The architecture similarly evidenced an equivocal stance. Its pro-jecting lower storeys hinted at a willingness to express the differing requirements ofthe various departments housed under the wards (a solution largely unthinkable inBritain before the War), whilst its CSSD suggested an engagement withcontemporary trends towards the industrialization and centralization of ancillaryprocesses. However, externally, its brick elevations and stone dressings were hardlyevocative of the "machine age" sophistication of Lever House. Perhaps mindfulof the blunt criticisms levelled at modernism by hospital staff before the War,New Guy's House promoted a stylistic and programmatic compromise betweenmodernity and tradition. Yet, elsewhere along the Thames, at St Thomas'sHospital, there were fewer reservations about creating a legibly modern architecturalform for the hospital.

Modernity and Efficiency: St Thomas's Hospital

Formerly the senior neighbour of Guy's Hospital near London Bridge, StThomas's Hospital relocated to Westminster in 1871. Its new buildings weredesigned by Henry Currey and were based on Paris's Lariboisiere pavilionplan hospital, with colonnaded Italianate pavilions aligned along the Thames.Subsequently extended, these formed the basis of the 600-bed twentieth-centuryhospital and medical school. The buildings suffered severe bombing in the SecondWorld War, forcing the Hospital temporarily to relocate to Godalming. The needto rebuild was readily evident and a Constructional Panel, consisting of Governors,medical staff, lay officers and outside consultants, was established in 1941 to

7' 'The new block at Guy's: a great addition to 73 King Edward's Hospital Fund for London,a famous London hospital', Illustrated London An evaluation of New Guy's House, London, KingNews, 6 May 1961. Edward's Hospital Fund for London, 1963.

72 Stark Murray, 'New block at Guy's: has anopportunity been missed?', The Times, 4November 1960.

50


formulate "a provisional programme for the entire remodelling of the Hospital".74In 1944 eminent town-planner Professor Sir William (later Lord) Holford7s wasappointed consultant architect with a brief to produce plans for a 1,000 bedhospital (in line with the 1944 Goodenough Report76). Furthermore the creationunder the NHS in 1948 of the 1,000-bed St Thomas's Hospital Group (includingother satellite hospitals) prompted attempts to centralize it on the main Westminstersite albeit a desire soon curtailed by the Ministry's 1949 800-bed limit on thesize of hospitals for civil defence reasons.

Holford, with Leslie Creed, produced the Preliminary report on the reconstructionof St. Thomass Hospital in May 1946, which suggested rebuilding the hospital onthe original foundations, and the sub-division of the Nightingale wards.77 Elaboratedin their third and final April 1950 report,78 the suggestion of greatest importancewas to be the diversion of Lambeth Palace Road to increase the hospital site from8.5 to 14.5 acres and "give more scope in planning the future accommodation."79Paid for by the Hospital's own endowment funds, the £3m scheme was completedin 1961.

Holford's recommendations bore little fruit: reconstruction work was initiallydelayed until December 1949 whilst the Ministry of Health debated St Thomas'sfuture in central London. Holford and Creed's proposals achieved a 1,000-bedhospital by heightening the rebuilt pavilions, subdividing the Nightingale wards,and inserting mezzanine floors into ancillary areas. This was less costly thancomplete rebuilding and advantageously retained Currey's riverside pavilions(reputedly demanded by Winston Churchill), whilst also retaining the Archbishopof Canterbury's view of Big Ben from his toilet in Lambeth Palace. However,apart from a number of contemporary, "New Look", chandeliers in the staffdining room for the 1951 Festival of Britain celebrations, Holford and Creedcompleted only one project at the Hospital. This small operating theatre block(Block Vlla) of 1956 was built on Currey's foundations as envisaged in theoriginal proposals, its faqade a plain, modern, pattern of brick and infill (Figure21).

In 1955 the discovery of widespread dry rot forced the abandonment of Holfordand Creed's plans for the rehabilitation of the existing structure. And so, for thenecessary wholesale rebuilding, a staff architect, William Fowler Howitt.80 wasappointed in 1955 to oversee the construction of the operating theatre block, and

7 Arthur Howard, 'Foreword' in William Committee on Medical Schools, Report of theHolford and Leslie Creed, Studies for the Inter-Departnmental Commnittee on Mediccal Schoolsreconstruction of St Thomass Hospital, Lambeth, (Goodenough Report), London, HMSO, 1944,London, St Thomas's Hospital, 1950. ch. 3, para. 27).

75 Gordon Cherry and Leith Penny, Holford: a 77 Reprinted in Holford and Creed, op. cit.,study in architecture, planning and civic design, note 74 above, appendix A.London, Mansell, 1986. 71 Ibid.

76The report proposed an annual intake of 79 Ibid., p. 25.100 medical students for a teaching hospital, " Howitt, a Rome scholar, had qualified fromdictating a minimum of 1,000 beds to offer a Dundee School of Architecture in 1948 andwide enough range of illness to its students worked on the Cork Regional Hospital project in(Ministry of Health, Inter-Departmental Dublin after the War.

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Figure 21: St Thomas's Hospital, London, Block Vlla, Leslie Creed, 1956.

prepare reconstruction schemes for the whole hospital. Advised by Holford, andgiven almost a tabula rasa, the plans progressed through a series of eight alternativesoutlining different building orientations and ward layouts, each one uneconomicalor unacceptable to the hospital's neighbours including the Church Commissioners(Lambeth Palace being adjacent), the London County Council (County Hall alsobeing adjacent), the Royal Fine Art Commission and the Palace of Westminster(over the Thames).When finally agreed, Scheme 8 formed the basis for the rebuilding of the 800-

bed hospital.8' The plans foresaw a massive 150 ft high, twelve-storey ward blockof 827 beds, to be built in one strip in four phases, parallel to the river (Figure22). Each phase was based on a T-shaped ward plan with the entrance to each28-bed ward (along with its associated ancillary accommodation) at the centreof the long side of the ward. Beds were placed in bays of four (in Nuffieldfashion), or in single rooms to permit the more flexible allocation of beds intomedical/surgical or male/female portions. Separate patient treatment rooms wereprovided to reduce cross-infection, and day rooms were incorporated to encourageearly ambulation. Beneath the ward block was to be a four-storey outpatientsand casualty block with operating theatres, linked to the wards via fourcommunications towers at the stems of the T-shaped blocks (Figure 23). On the

81 William F Howitt, Proposals for therebuilding of St Thomas's Hospital, London, StThomas's Hospital, 1957.

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JIL.Aa. :effFigure 22. St Thomas's Hospital, London, rebuilding scheme, William Howitt, 1956-63. Viewof model. From George H Bell (ed.), Hospital and medical school design, Edinburgh andLondon, E & S Livingstone, 1961.

2 2

2 10

1 2d

-A[jj 21 2213 20 6 7

~~~~~1Singte Bed Word 19 thees' Cloakroom

2 h-Bed Ward 20 Students Test Laboratory2 2 3 Balcony 21 Telephlone

WARD BLOCK

hDoy RoornS Nurses' Station6 Doctors' Room7 Sister's Room8 Dity Osposal9 Wash-up10 Treatment Room11 Kitchen12 Sterile Store13 Slivce Room1U Potients' Lonaries15 Potcnts' Bathroom16 Housenimds' Closet17 Linen StoreIB Visitors, Room

I I 10 2 30 AS0 00 00 1O 0 3 FEET

o I s n 15 20 25 30s 30 a .5

Figure 23: St Thomas's Hospital, London, rebuilding scheme, William Howitt, 1956-63. Planof ward. From George H Bell (ed.), Hospital and medical school design, Edinburgh andLondon, E & S Livingstone, 1961.

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Jonathan Hughes

lower levels were to be central catering and sterile supplies departments servingthe whole hospital. The scheme echoed continental hospital layouts, in particularStockholm's Soder Hospital and Basel's Burgerspital, with their ward towers andlower ancillary blocks buildings visited during Howitt's tour of modern Europeanhospitals in 1956.82 With its pneumatic tubes for the delivery of medical records,laboratory specimens and notes, as well as its bed-head sited piped medical gasesand suction, Howitt's scheme embodied many of Friesen's principles. Its centrallaundry, kitchen and CSSD removed catering and cleansing functions from thewards, whilst its Intensive Care Unit (one of the first in England) applied thesame principle of specialization, grouping all patients in need of special care ina dedicated unit rather than on individual wards.83The first stage of the £7-8m plan, announced in January 1958, received an

enthusiastic press-commentators noting the facilities of this "Dream Hospital":

Britain's boldest hospital plan ... the block will be so modern it will be a patients' anddoctors' paradise ... it will have: panoramic views over London, menu meals on individualtrays, patient-to-nurse call system, bedside radio links, and air conditioning ... [It will be an]ultra-modern hospital which will tower over Westminster.84

Likewise, the Star's correspondent observed that "It will be in every way acomplete masterpiece in hospital building and one of the best equipped in theworld for medical work in all its most up-to-date scientific aspects."85 After adecade of inaction, here at last was proof that the NHS was to back its radicalsocial programme with buildings to match. The optimism was, however, to be short-lived, as progress was hindered by replanning to facilitate "greater centralization andthus better management",86 Ministry delays, shortages of materials and the scarcityof qualified architects. Given the limited nature of the work available in Howitt'soffice and the Ministry's low pay-scales, the office's inability to attract qualifiedstaff was placing the whole project in jeopardy: as Howitt wrote to Holford,"our state is desperate".87 The publication in 1962 of Enoch Powell's ten-yearHospital plan proved pivotal, giving St Thomas's additional responsibilities andsuggesting an optimum capacity of 1,255 beds. It proved impossible for thestretched architect's department to replan the building to accommodate theadditional 400 beds and subsequently, on 7 August 1963, Yorke Rosenberg &Mardall were appointed to prepare a new master plan for the hospital-the

82 Howitt recalls visiting Denmark, Norway, 85T Watson, 'Arise St Thomas's finestSweden, Germany and Switzerland to look at hospital in the world', Star, 15 December 1959,current building. In conversation with the author, p. 5.December 1992. 86'Work to start on rebuilding £13m hospital',

8' E M McInnes, St Thomas' Hospital, 2nd The Times, 23 January 1963.ed., London, George Allen & Unwin, 1990, p. 87Holford Archives, University of Liverpool,182. dated 5 July 1963.

84 Newspaper cutting, St Thomas's Hospitalarchives, no date or bibliographic details.

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-~~.iFigure 24: St Thomas's Hospital, London, rebuilding scheme, William Howitt, 1956-63. Viewof east wing. (Photo: Jonathan Hughes.)

ensuing press criticism of the confusion eclipsing the completion of the first andonly phase of Howitt's design (Figure 24).

Postscript

By the time of the completion of St Thomas's East Wing, British hospitaldesigners were widely adopting the "matchbox on a muffin" as an appropriateform for the modem hospital. The relative press silence which greeted thecompletion of the East Wing is perhaps as revealing as the criticism which wasaimed at New Guy's House, and highlights the legibility of the programmaticand stylistic differences between the two projects. The "matchbox on a muffin"-andthe social, medical and architectural cross-currents which informed its design-hadbeen rapidly naturalized as a rational solution to the needs (both aesthetic andclinical) of the post-war hospital, and was to remain an influential model ofhospital design well into the 1960s, even as dissenting voices were beginning toquestion the inflexibility of the solution, with its reliance on high-tech transportationsystems and its inability to accept incremental expansion and change. Whereasverticality and mechanization had underwritten the "matchbox on a muffin",subsequent models would propose horizontal and low-tech modes of circulationand, out of necessity, came to offer the dominant principles for hospital designin the capital- and energy-starved 1970s and beyond. Yet during the late 1950s

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and early 1960s, in an era of self-conscious social and physical modernization,with an optimistic attitude to technology and progress, hospital authorities,designers and the public could briefly agree that the "Dream Hospital" wasindeed a "matchbox on a muffin".

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the matchbox ona muffin: thedesign hospitals early · the "matchboxona muffin": ......

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